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Archive for March, 2008

Sickle Cell Disease Update

Any patient screened positive or with known sickle cell disease must have a hematology consult before elective surgery, procedures or admission.

Written by reuben

March 26th, 2008 at 5:39 pm

Posted in Sickle Cell

Q Tips

  • Remember that you can use succinylcholine intramuscularly if you cannot obtain iv access in a timely manner — the dose is 3-4 mg/kg (with a max dose of 150mg).
  • When discharging patients, be sure to write a reevaluation note documenting improvement in symptoms when appropriate. When signing patients out AMA, document reasons for patient leaving & your discussion with them. This is much more important than the patient actually signing the AMA form.
  • We’ve had several arrests 2′ hypoxia during intubation attempts — in a patient with low saturations on arrival, the 1st intubation attempt should be by a senior EM resident, followed rapidly by the attending to ensure rapid airway establishment.
  • In patients who present with hypoglycemia, remember that you should start them on a D5 drip after treating the initial value with D50. Or feed them!
  • In patients that are HIV+ & present with a headache – be sure to document an opening pressure when doing the LP. This is an important result in helping to diagnose the etiology of the headache.
  • Remember that if a patient expires in the ED – even if they are admitted – change the dispo to “expired”. This is how we capture charts for review.
  • On the other hand, if admitted patients are discharged from the ED by the medicine team – do not change the disposition. This will falsely lower our admission statistics.
  • When medical students are ordering medications, remind them that they must change the “ordering physician” name to the attending’s name they are working with – pharmacy will not fill the order if it is done by a medical student which results in a delay of the patient getting their meds.
  • When ordering medications, please DO NOT FREE TEXT! Pharmacy tracks this & we have to review these. In addition, you will not get any drug interaction or allergy prompts. This includes all drips – pressors, heparin, nitroglycerin, etc. If you cannot find what you are looking for … ask Kevin or Neal where to find it (or anyone else who’s around!).
  • When ordering lovenox, be sure to type in the patient’s weight in the comments area … you can save yourself a phone call from pharmacy inquiring about the weight.

 

Written by reuben

March 23rd, 2008 at 1:58 am

Posted in Pearls

Q Tips (Sepsis)

Overall Sinai is doing much better in regards to care of the septic patient in 2008.  In January, our MICU admits with sepsis had lactates drawn 100% of the time (vs. 66% in Dec 2007).  However, only 50% (5/10) of patients eligible for the EGDT protocol (lactate >4 or hypotension) went through the protocol.  The following management suggestions were culled from the 10 MICU admits with severe sepsis:
  • EGDT Eligibility: Septic patients with low BP or lactate over 4 should be considered for Early Goal Directed Therapy.  The inclusion criteria and pathway are available in copies, or at critical-care.info.  Anyone unfamiliar with our protocol, please print a copy out and check it out.
  • Pressors: Dopamine vs. Levophed.  Both remain in the surviving sepsis campaign recommendations as first line agents for hypotension in sepsis.  Levophed is the pressor of choice in our protocol.  From the SSC 2008 recommendations: Norepinephrine is more potent than dopamine and may be more effective at reversing hypotension in patients with septic shock. Dopamine may be particularly useful in patients with compromised systolic function but causes more tachycardia and may be more arrhythmogenic (78). It may also influence the endocrine response via the hypothalamic-pituitary axis and have immunosuppressive effects.
  • Initial Hypotension in Sepsis:  Our protocol flows from fluids, to pressors, to steroids, to blood products to dobutamine, to intubation, to yet more fluids.  These elements are in sequence on the protocol, and will remain as they are for clarity, however, there is one instance when they may need to be instituted in parallel.  If your patient’s MAP is very low initially, start pressors even if no fluid has been given yet.  Although there is no data to support a specific cutoff, a MAP<50 is reasonable.  Fluid resuscitation ought to begin at the same time.  Give the empiric 20 cc/kg bolus as part of the EGDT protocol.  Pressors will affect your CVP measurements, so the key is to get the CVP up to >8 while on pressors, and then titrate down as MAP stays > 65. As you titrate down, you’ll see the CVP will drop–give more fluids.  If the patient’s blood pressure is > 65 with low dose pressors and CVP > 8, turn off the pressors for a few minutes and see where the CVP goes.
  • Documentation: Please document.  HPI should be something related (not the STD HPI).  Attendings can document Critical Care time for patients requiring EGDT.  If you go through the EGDT protocol document your CVPs as they may not be recorded by the resus RN.  We are working on a more complete EGDT documentation record.
  • Steroids: Cortisol stimulation testing has gone by the wayside s/p the recent CORTICUS trial.  Our protocol has dropped Dexamethasone in favor of Hydrocortisone to be given only in patients with septic shock refractory to vasopressor therapy.
  • Lactates: Every septic patient going to the MICU had a lactate drawn.  Excellent.  Fewer had them repeated.  You should repeat a lactate (as easy as drawing a GEMM) to evaluate oxygen delivery in the prbc/dobutamine/intubation part of the EGDT protocol – and a declining lactate at 6 hours is an important prognostic marker.
  • Cardiac Biomarkers in Sepsis: Watch out for confounding +Troponins in your septic patient.  If they have no story or EKG changes, the + troponin that the lab called you about may be leak related to their sepsis, rather than a primary coronary/myocardial event.  If you still suspect severe sepsis is the prime mover, don’t forget to continue EGDT if you have a lactate over four or hypotension.

 

Written by reuben

March 23rd, 2008 at 1:55 am

Posted in Pearls,Sepsis

Medical Examiner Cases

Reportable Deaths:


All forms of criminal violence, unlawful act or criminal neglect

All Accidents (motor vehicle, home, falls, industrial)

All suicides

All deaths caused or contributed to by drug/chemical overdose or poisoning

Sudden death of a person in apparent good health

Deaths unattended by a physician

Deaths of all persons in legal/court ordered detention

Deaths during or due to complications of diagnostic or therapeutic procedures

Deaths related to employment

Deaths which occur in any suspicious or unusual manner

Fetus born dead due to maternal trauma or drug abuse or in the absence fo a physician/midwife
Any death that is not 100% due to natural disease must be reported to the OCME even if it takes years for an injury to result in the fatality.
There is no 24 hour rule in NYC: Hospital deaths entirely from natural causes in which a diagnosis has been made with reasonable medical probability, despite the fact that the patient survived less than 24 hours in the hospital, need not be reported to the OCME.

Examples of Proximate Cause:
Arteriosclerotic Cardiovascular Disease
Hypertensive Cardiovascular Disease
Asthmatic Bronchitis
Pulmonary Emphysema
Lobar Pneumonia
Pancreatic Carcinoma
AIDS
AIDS due to Chronic Intravenous Drug Use
Chronic Alcoholism


Examples of Mechanisms/Immediate Cause:
Bronchopneumonia
Pulmonary Embolism
Acute Myocardial Infarct
DIC
Cardiac Arrythmia
Congestive Heart Failure

Written by reuben

March 11th, 2008 at 1:54 am

Posted in Death

Acute Pain Services Available

1. The Faculty Practice Associates Anesthesiology Pain Management Division provides coverage at all times.  As of November 2007, the service established a 20 minute benchmark from the time that a page is received until a practitioner arrives at the patient’s bedside (pager 2738).

2. The FPA Palliative Care Consultative Team provides services for patients with pain who can benefit from the comprehensive interdisciplinary approach to medical management of co-morbidities.  Their team of MDs, NPs,  social workers, massage therapists and chaplain is available for consultation on weekdays (pager 9399).  At all other times, Palliative Care can be contacted for support by pager (917-632-6096).

Written by reuben

March 6th, 2008 at 1:44 am